Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems 11th Edition TESTBANK

Lewis's Medical-Surgical Nursing: Assessment V V V V




and Management of Clinical Problems 11th Edition
TESTBANK


Table of Contents V V




Chapter 1. Professional Nursing
V V V




MULTIPLE CHOICE V




1. The nurse completes an admission database and explains that the plan of care and
V V V V V V V V V V V V V




discharge goals will be developed with the patients input. The patient states, How is this
V V V V V V V V V V V V V V V




different from what the doctor does? Which response would be most appropriate for the
V V V V V V V V V V V V V V




nurse to make?
V V V




a. The role of the nurse is to administer medications and other treatments
V V V V V V V V V V V




prescribed by your doctor.
V V V V




b. The nurses job is to help the doctor by collecting information and
V V V V V V V V V V V




communicating any problems that occur.
V V V V V




c. Nurses perform many of the same procedures as the doctor, but nurses are
V V V V V V V V V V V V




with the patients for a longer time than the doctor.
V V V V V V V V V V




d. In addition to caring for you while you are sick, the nurses will assist you
V V V V V V V V V V V V V V




to develop an individualized plan to maintain your health.
V V V V V V V V V




ANS: D V




This response is consistent with the American Nurses Association (ANA) definition of
V V V V V V V V V V V




nursing, which describes the role of nurses in promoting health. The other responses
V V V V V V V V V V V V V




describe some of the dependent and collaborative functions of the nursing role but do not
V V V V V V V V V V V V V V V




accurately describe the nurses role in the health care system.
V V V V V V V V V V




DIF: Cognitive Level: Understand (comprehension) REF: 3
V V V V V V




TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
V V V V V V V V V V

,2. The nurse describes to a student nurse how to use evidence-based practice guidelines
V V V V V V V V V V V V




when caring for patients. Which statement, if made by the nurse, would be the most
V V V V V V V V V V V V V V V




accurate?
V




a. Inferences from clinical research studies are used as a guide.
V V V V V V V V V




b. Patient care is based on clinical judgment, experience, and traditions.
V V V V V V V V V




c. Data are evaluated to show that the patient outcomes are consistently
V V V V V V V V V V




met.
V




d. Recommendations are based on research, clinical expertise, and patient V V V V V V V V




preferences.
V




ANS: D V




Evidence-based practice (EBP) is the use of the best research-based evidence combined
V V V V V V V V V V V




with clinician expertise. Clinical judgment based on the nurses clinical experience is
V V V V V V V V V V V V




part of EBP, but clinical decision making should also incorporate current research and
V V V V V V V V V V V V V




research-based guidelines. Evaluation of patient outcomes is important, but
V V V V V V V V V




interventions should be based on research from randomized control studies with a large
V V V V V V V V V V V V V




number of subjects.
V V V




DIF: Cognitive Level: Remember (knowledge) REF: 11
V V V V V V




TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
V V V V V V V V V V




3. The nurse teaches a student nurse about how to apply the nursing process when
V V V V V V V V V V V V V




providing patient care. Which statement, if made by the student nurse, indicates that
V V V V V V V V V V V V V




teaching was successful?
V V V




a. The nursing process is a scientific-based method of diagnosing the
V V V V V V V V V




patients health care problems.
V V V V




b. The nursing process is a problem-solving tool used to identify and treat
V V V V V V V V V V V




patients health care needs.
V V V V




c. The nursing process is based on nursing theory that incorporates the
V V V V V V V V V V




biopsychosocial nature of humans.
V V V V

, d. The nursing process is used primarily to explain nursing interventions to
V V V V V V V V V V




other health care professionals.
V V V V




ANS: B V




The nursing process is a problem-solving approach to the identification and treatment of
V V V V V V V V V V V V




patients problems. Diagnosis is only one phase of the nursing process. The primary use of
V V V V V V V V V V V V V V V




the nursing process is in patient care, not to establish nursing theory or explain nursing
V V V V V V V V V V V V V V V




interventions to other health care professionals.
V V V V V V




DIF: Cognitive Level: Understand (comprehension) REF: 7
V V V V V V




TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
V V V V V V V V V V




4. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel
V V V V V V V V V V V V V V V V V




comfortable leaving my children with my parents. Which action should the nurse take
V V V V V V V V V V V V V




next?
V




a. Reassure the patient that these feelings are common for parents.V V V V V V V V V




b. Have the patient call the children to ensure that they are doing well.
V V V V V V V V V V V V




c. Gather more data about the patients feelings about the child-care
V V V V V V V V V




arrangements.
V




d. Call the patients parents to determine whether adequate child care is
V V V V V V V V V V




being provided.
V V




ANS: C V




Since a complete assessment is necessary in order to identify a problem and choose an
V V V V V V V V V V V V V V




appropriate intervention, the nurses first action should be to obtain more information.
V V V V V V V V V V V V




The other actions may be appropriate, but more assessment is needed before the best
V V V V V V V V V V V V V V




intervention can be chosen.
V V V V




DIF: Cognitive Level: Apply (application) REF: 6-7
V V V V V V




OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
V V V V V V V

, MSC: NCLEX: Psychosocial Integrity
V V V




5. A patient who is paralyzed on the left side of the body after a stroke develops a
V V V V V V V V V V V V V V V V




pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
V V V V V V V V V V V V




a. Impaired physical mobility related to left-sided paralysis
V V V V V V




b. Risk for impaired tissue integrity related to left-sided weakness
V V V V V V V V




c. Impaired skin integrity related to altered circulation and pressure
V V V V V V V V




d. Ineffective tissue perfusion related to inability to move independently V V V V V V V V




ANS: C V




The patients major problem is the impaired skin integrity as demonstrated by the
V V V V V V V V V V V V




presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and
V V V V V V V V V V V V V V V V V




pressure by frequently repositioning the patient. Although left-sided weakness is a
V V V V V V V V V V V




problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is not
V V V V V V V V V V V V V V V V




appropriate for this patient, who already has impaired tissue integrity. The patient does
V V V V V V V V V V V V V




have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates
V V V V V V V V V V V




more clearly what the health problem is.
V V V V V V V




DIF: Cognitive Level: Apply (application) REF: 7-9
V V V V V V




TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
V V V V V V V




6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume
V V V V V V V V V V V V V




related to excessive diaphoresis. Which outcome would the nurse recognize as most
V V V V V V V V V V V V




appropriate for this patient?
V V V V




a. Patient has a balanced intake and output.
V V V V V V




b. Patients bedding is changed when it becomes damp.
V V V V V V V




c. Patient understands the need for increased fluid intake.
V V V V V V V




d. Patients skin remains cool and dry throughout hospitalization.
V V V V V V V




ANS: A V